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CLIENT: So, I keep wanting to kill myself. Like, most of the time, and I don't really know what to do about that.
(pause from [00:00:22] to [00:00:51])
THERAPIST: Pretty much unchanged?
CLIENT: Yeah. (pause) I mean, I don't. (pause) I don't know. (pause) Pretty sure James doesn't know this.
THERAPIST: This as in you keep wanting to, and keep thinking about it?
CLIENT: Yeah. (pause from [00:01:42] to [00:02:08]) It was really bad. (pause [00:02:09] to [00:02:29])
THERAPIST: Most of the time?
CLIENT: Yeah. (pause from [00:02:33] to [00:03:03])
THERAPIST: Does the sadness feel pretty monolithic and disconnected and not caused by X, Y or Z. Not made better or worse by X, Y or Z?
CLIENT: Yeah, it's just kind of there.
THERAPIST: Yeah. (pause from [00:03:28] to [00:04:27]) I, it's complicated but I think that one aspect of both the, your ongoing thoughts on suicide and the kind of undifferentiated quality of the sadness, is to disguise, more particular ways that you feel and think that you think. I'm not doubting in any way that you are feeling as suicidal as you have been, or as bad as you have been. But I think, for example, this suicidal thought function both is a signal and a symptom. Signal is mostly saying ouch, I cannot bear this anymore. That's the communicative aspect of it in a way. I think it's like, you want to be dead because you hurt so much, and you don't think it's going to be any different and the reasonable thing is to be dead.
Just like somebody who has some advanced stage of cancer and is only going to get worse, or only going to lose their mind, and only going to go on tons of drugs, it's only going to cost everybody a lot of money and resources, so like, you know, it's arguably, reasonably they decide okay, let's pull the plug. My impression is that there is a part of you that is like that. It hurts so badly and you don't see it changing, so you've just had enough.
But I think that's not all. I think there's also a way in which, focusing on, as far as the communicative goes and as far as the safety goes, focusing on suicide is important. But I think it can also sort of drown out other things. In some other, I think, feeling like the depression is for its all practical purposes, purely biological in some sense. It is just some kind of (inaudible). I'm sure there's a biological component to it, I'm not saying otherwise. But, then it's like, this kind of ongoing thing, that's irrespect, relatively irrespective of circumstances and (pause) the same most of the time, it isn't. I think there is something that how it feels as though it is, but it's like a bit of a disguise, or a bit of a defense against the more particular aspects of it, and of what hurts you.
(pause from [00:09:14] to [00:14:21] What are your thoughts?
CLIENT: I don't know. (pause from [00:14:28] to [00:14:42]
THERAPIST: Well in that case, let's back up.
CLIENT: Okay.
THERAPIST: Tell me about the suicidal thoughts.
CLIENT: There's not very much to tell. They are there all the time.
THERAPIST: Must see images of yourself hurting yourself?
CLIENT: Yeah.
THERAPIST: Like cutting your throat?
CLIENT: Yeah.
THERAPIST: That's a big one?
CLIENT: Pretty much.
THERAPIST: What's another one?
CLIENT: It's pretty much that.
THERAPIST: Is it hard to tell anyone? Hard to (inaudible)
CLIENT: Hard to, yeah.
THERAPIST: Because you are horrified?
CLIENT: I'm embarrassed. (chuckles) (pause) Yeah.
THERAPIST: You can see, like stabbing yourself, hanging yourself, jumping out the window?
CLIENT: Yeah. (voice breaks)
THERAPIST: Taking pills, shooting yourself?
CLIENT: Not shooting myself, but taking pills, stabbing myself.
THERAPIST: It seems like there is something about the violence of it, that's part of it.
CLIENT: I guess so.
THERAPIST: Like it's not just sort of, like a wanting to sleep forever kind of thing, it's probably about how you are going to get there. That's it's going to violent, and bloody. I know you said something about, it's practical because that's quick. I think we (inaudible) some things. You know, the time to take pills or hang yourself or something like that. But it seems like maybe there's also something about it, that's violent and bloody. (pause) I'm jumping, it's partly about self-hatred. Do you have any thoughts about what it could be about? What it is about the thoughts that strike you?
CLIENT: (pause from [00:18:55] to [00:19:51]) I have no idea. (pause from [00:19:54] to [00:21:29] I don't know. I,
(pause from [00:21:31] to [00:22:24]) I'm sorry.
THERAPIST: It's all right. You have nothing to (inaudible), you seem a bit moved. I think you are holding yourself a little bit, I don't know if you're, if it's the starting to talk about, or thinking about something else.
CLIENT: I'm thinking about the clock. That's all.
THERAPIST: Sure? (pause) Like, as though you were a grad student and working on your thesis or paper and kind of always handing your head, I hate to come with a really macabre example (chuckles). Like that where, depending on how you are doing is sort of right there, on your mind?
CLIENT: A little bit. (pause from [00:24:00] to [00:24:32])
THERAPIST: Do you know how it feels to have a flare like that? For example, if it was a thesis, you could be, gosh it makes me feel stressed, it makes me feel like whatever I'm doing I'm really not doing what I'm supposed to be doing, which is the thesis. Or it could be, well, I've seen other thesis, probably because it's interesting, I'm really in to it at this point and I kind of can't wait to get back to it. Or, there's this feeling of dread, I know I'm going to have to sit down with it, and I just feel it and I feel the dread all the time whenever I'm thinking about it. Do you feel dread, do you feel fear, do you feel sense of security, do you feel...
CLIENT: I feel mostly interested. (pause) Yeah.
THERAPIST: As in like, you are thinking about it and you are thinking this is something you are interested in doing?
CLIENT: Yeah. (voice breaks) Yeah.
THERAPIST: As though it were, in some sense any other activity that you were free to do.
CLIENT: Yeah. (pause from [00:26:01] to [00:26:31])
THERAPIST: So that's mostly what you are feeling now? (pause from [00:26:33] to [00:26:48]) Are you (inaudible)?
CLIENT: Yeah, I am. (pause) I don't want to.
THERAPIST: Hard to stop yourself? How have you managed for so long?
CLIENT: I'm married to James. Yeah. (pause) It's just, I don't know what I'd do.
THERAPIST: You are working pretty hard though. (pause) It has to be hurting inside.
CLIENT: Yeah it is.
THERAPIST: I guess wanting, maybe one of the only benefits of being in the hospital is that you don't have to work so hard now.
(pause from [00:28:55] to [00:29:23]) I also imagine you, went back over it. Are you warning me, are you telling me like, look, I don't think I can keep this up much longer? (pause) I know it often feels a little touch and go. Yesterday you said you'd be okay until today. Today it sounds like you're not so sure anymore.
CLIENT: No.
THERAPIST: And Candace is (inaudible).
CLIENT: That should help. Maybe. I think.
THERAPIST: (inaudible phrase).
CLIENT: Yeah. (inaudible) (pause from [00:31:27] to [00:32:07])
THERAPIST: You don't seem to be feeling better. I mean I've, (pause) How should having Candace here help? I'm not doubting, like I know how often having people visit helps. Like with Amanda for example.
CLIENT: There's a (pause), it's some combination of distraction, and (pause) I guess that's it.
THERAPIST: You what?
CLIENT: It's mostly just a distraction.
THERAPIST: I see. I would have guessed that it's a bit of support, but maybe that's not right. (pause) I mean I'm not trying to put a happy face on it, I just, I don't know. But your impression is that it's mostly a distraction?
CLIENT: Yeah. (pause from [00:34:39] to [00:35:25]).
THERAPIST: Have they given you someone else to focus on?
CLIENT: Yeah. (pause from [00:35:30] to [00:36:15])
THERAPIST: I'm wondering if you are having a hard time remembering how you feel from one day to the next. For example, when you tell me today about thinking about suicide a lot, and picturing it a lot, and thinking of the things that you could do to yourself, and feeling really, really sad, through today. You haven't said that the other days this week, and last week I think you said a couple of times, you felt the ECT was helping. So, this leaves me a little confused about, and I can imagine a few scenarios. One is, see, I imagine where there are sometimes when you're thinking about suicide going really bad, that you might have mentioned or with James you don't talk about it as much as you're feeling it. I think with me, you try to, when you are really feeling it, I think you try like today to come in and put it out there.
CLIENT: I try to.
THERAPIST: That is my impression so, when you say something like today you are feeling that, I don't know if you are sad or the implication is that this has been an ongoing thing. For a long time. That leaves me wondering have you not been saying it, or are you misremembering that now, or are you dissociated it from it on other days? (inaudible) we really haven't seen much. Does it make sense why I'm confused?
CLIENT: Yeah. (pause from [00:38:47] to [00:39:31])
THERAPIST: I can tell you my hunch. But you actually might know, so if you have a thought ...
CLIENT: I don't know. I really don't.
THERAPIST: Do you have an idea?
CLIENT: (pause from [00:39:46] to [00:40:55] I'm not sure.
THERAPIST: My sort of tentative suspicion, or hunch is that you're depression is very good at making you forget in a particular way. Like, its sort of props include a conviction that it's always the way it is when you feel really bad. Don't get me wrong, I know it's often been just, you've told me often that it's been like that, or it's been really awful, I don't mean to say it's been like that (inaudible). But I think your depression is pretty good at making you feel like it's always been like that. Over the last few weeks, I can tell you, it, that's not what you've said. I mean, you've told me at a number of points, even I think at the end of last week, although you were quiet, that you felt like the ECT was working and things weren't as bad.
You know, you weren't like skipping around, but it wasn't like this. It's a little more ambiguous than yesterday and Tuesday, at least for me. Because you were very quiet, but I suspect that if you had been, you sound worried about the suicidality now. Sometimes you are. I think if you had been as worried or more worried yesterday or Tuesday you would probably, as you did today, have said something about it. So like, I don't think it's as though you are thinking about it 75 percent of the time now and you were thinking about it 5 percent of the time yesterday or Tuesday. It seems like you crossed some, like I said, you crossed some threshold, but that part of how that happens for you, is that when it happens, you feel like it's actually always been there. [00:44:07]
Another possibility would be that, it is there and you are disassociated from it. And then it sort of comes back but you're not as ... I don't think that's what it is. I mean, I've seen that before, but I don't think that's what's going on with you. I think that it's more like kind of a trick the depression plays to make you feel like it's always at the absolute worst, all the time.
CLIENT: To make me think that.
THERAPIST: Yeah and if it were just my own sort of intuition that it felt that for other times, I trust what you said more. But when it's what you've actually said at other times, I'm inclined to trust that. [00:45:13] (pause) We should stop, but you, I think you sound fairly confident that you will make it til Candace gets here.
CLIENT: Yeah.
THERAPIST: Yeah. Okay. Then we will meet tomorrow. Okay, all right. Call me if something changes.
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